What is good service design? What are examples of things gone wrong and why? I am collecting thoughts and experiences here about services in general and health services in particular and am looking forward to your comments.

Saturday, 30 November 2013

My second paper just got published in AMJ, an open access journal. Below the abstract and the link to the journal. Very excited to see this finally happen.

Why are healthcare services fuzzy?

Abstract

Background
Healthcare organisations are an
enigma to many people in- and outside the service. Organisational
fuzziness is a common state, characterised by a lack of clarity, lack of
awareness, lack of organisational knowledge, and the reliance on
practice and custom instead of transparency. Aims
The
objective of this study was to obtain a better understanding of what
causes this fuzziness and provide an actionable description of fuzzy
organisations. Such a description is essential to managing and
preventing organisational fuzziness. Method
We
used a longitudinal case study in an integrated health- and social care
organisation to obtain a thorough understanding of how the organisation
functions. These in-depth insights allowed the identification of three
generators of fuzziness.Results
We found that
the three main generators of organisational fuzziness are change,
informal organisation and complexity. Organisational fuzziness is thus
partly due to the inherent complexities of human systems. However, also
continuous change and the inability of the system to adapt its formal
structures resulted in structures deteriorating or no longer being
appropriate.Conclusion
Existing approaches to
explain unclear or absent structures in healthcare organisations by
describing these organisations as complex adaptive systems (CAS) are too
simplistic. While aspects relating to people and their interactions are
indeed complex, fuzziness of structural aspects are often the result of
continuous change and insufficient organisational capacity to adapt to
it.

Tuesday, 8 October 2013

The big innovation in the 19th and 20th century was the acknowledgement that health is a systemic issue. If people do not seek medical advice for small problems due to economic reasons, these small problems can become big problems and cause further poverty. This realisation led, for example, to the establishment of the NHS in 1948.

Nowadays we are facing the sustainability challenge: will we be able to keep affording the systems set up as a result? One problem is the ageing populations of many developed nations – it is estimated that in the US on average between 25% and 56% of healthcare spending occurs in the final 12 months of life. A second problem is, ironically, continuing progress in the medical sciences which allows us to treat more diseases and prolong lives. But the associated costs are spiralling out of control. Also, scientific progress creates illusions regarding what it possible and feasible. Combined with the lack of a culture that discusses death as a part of life many doctors find themselves under pressure to do whatever is possible, regardless of quality of life – or costs.

The latter point – placing a monetary value on life – might sit very uncomfortably with some readers. However, when we look at health as a systemic issue the question of money is bound to arise in one form or another. Every dollar or pound can only be spent once. A cancer treatment that prolongs life for a couple of months (at often a pretty terrible quality of life) can cost £40,000, which could also pay the annual salary of a palliative nurse. In the United Kingdom the discussion is open. The National Institute for Clinical Excellence (NICE) makes decisions about which treatments are covered by the National Health Service (NHS) based on the calculation of quality-adjusted life years. But systems which do not have this transparency, such as the fragmented German system of different public and private payers and various associations representing healthcare providers, also have to make decisions regarding which treatments are considered effective and value for money in order to contain costs and kept health insurance affordable.

Another issue which affects the sustainability of our healthcare systems is the human side. Organisational structures are filled by people, both staff and patients. As the people in them change structures have to adapt and vice versa. A system in which structures and people are out of synch will not work in the long run. A popular contemporary line of argument is that because healthcare is fundamentally an interaction between people, it is complex and non deterministic. Other arguments for this complexity model are based on the enormous variety of issues faced by healthcare providers, although this is strictly speaking not a characteristic of complexity but rather indicates a complicated problem. Semantics aside, the focus on complexity are as one-sided as the earlier models of rational technocratic top-down blueprints which the complexity model seeks to supersede. It is not a question of one or the other, but rather ‘horses for courses’.

A climbing rose is a good simile for how organisational success depends on interactions between staff and structures. A climbing rose (staff) requires a scaffold (structures) to reach its full potential. The shape of the scaffold will have a key influence on the shape of the final rose bush, but it is not possible to completely determine the shape of the bush from the shape of the scaffold and sometimes it becomes necessary to change the shape of the scaffold. On the other hand, the best scaffold in the world is worthless without the right, good, healthy plants.

I think the challenges we face are so big that a more open discussion regarding end of life care will be inevitable. On the other hand, a new direction in the policy debate that seeks to reconcile technocratic approaches to structures with insights about the complexity of human interaction should help to ensure a system that can adapt to changing environments and new challenges.

Tuesday, 1 October 2013

My paper is finally out - I submitted it last year in June and it was published as early view this July. I carried out a study with three groups of stakeholders and assessed to which degree they agree on priorities for service design.

Of course I am biased, but I think this is really important and interesting research as it is the first time that we can quantify the contribution of different stakeholder groups which historically had different amount of influence on the service design process. For example, experts and policy makers usually have a lot of influence, carers (and patients, but unfortunatly I was not able to include them) usually have much less. One of the reason why they have so much less influence is because those with the power over the process doubt how useful their contribution can be (I guess you can call this a certain degree of professional arrogance) and this is exactly where my work chimes in. I can actually show that they can contribute new idea which established stakeholders recognize as valuable.

Exploring the boundary of a specialist service for adults with intellectual disabilities using a Delphi study: a quantification of stakeholder participation

Eva-Maria Hempe, Cecily Morrison, Anthony Holland

Background

There are arguments that a specialist service for adults with intellectual disabilities is needed to address the health inequalities that this group experiences. The boundary of such a specialist service however is unclear, and definition is difficult, given the varying experiences of the multiple stakeholder groups.

Objectives

The study reported here quantitatively investigates divergence in stakeholders’ views of what constitutes a good specialist service for people with intellectual disabilities. It is the first step of a larger project that aims to investigate the purpose, function and design of such a specialist service. The results are intended to support policy and service development.

Study design

A Delphi study was carried out to elicit the requirements of this new specialist service from stakeholder groups. It consisted of three panels (carers, frontline health professionals, researchers and policymakers) and had three rounds. The quantification of stakeholder participation covers the number of unique ideas per panel, the value of these ideas as determined by the other panels and the level of agreement within and between panels.

Findings

There is some overlap of ideas about of what should constitute this specialist service, but both carers and frontline health professionals contributed unique ideas. Many of these were valued by the researchers and policymakers. Interestingly, carers generated more ideas regarding how to deliver services than what services to deliver. Regarding whether ideas are considered appropriate, the variation both within and between groups is small. On the other hand, the feasibility of solutions is much more contested, with large variations among carers.

Conclusions

This study provides a quantified representation of the diversity of ideas among stakeholder groups regarding where the boundary of a specialist service for adults with learning disabilities should sit. The results can be used as a starting point for the design process. The study also offers one way to measure the impact of participation for those interested in participation as a mechanism for service improvement.

Tuesday, 24 September 2013

Two interesting links, explaining why US Health Care costs are so high (also in comparison to other developed countries). In a nutshell: lack of transparency about costs + inherent power imbalances = a flawed market.

Tuesday, 17 September 2013

I have been quiet for an aweful long time - and a lot has happened since. Most importantly: my thesis is all done, approved and on the shelves of the Cambridge libary, so I am now a doctor (yeah). I since moved back to Germany and for the last 14 month I have been working as a consultant in Munich, with a focus on health care projects.

In case you are interested, I pasted the abstract of my thesis below. If you want to read the full thing, drop me a message (ideally with a bit of beackground on what you do and why you are interested in my work) and I can send you the pdf.

Applicability of Engineering Design Processes in
the Design of Integrated Intellectual Disabilities Services in England

This
dissertation investigates the applicability of engineering design processes for
the design of integrated intellectual disabilities (ID) services in England. It
aspires to contribute to the development of an engineering-design-style (ED)
design process for a particular integrated health and social care organisation.
Healthcare services in the developed world are faced with challenges arising
from a growing burden of chronic disease and aging populations. In order to
address these challenges, a more holistic understanding of health that also
considers social factors is needed. A local integrated care service for people
with intellectual disabilities constitutes an interesting case study as these intellectual
disabilities services have several decades of experience in integrating health-
and social care.

This
study contributes to knowledge by elicitating the need to combine the
engineering tradition of design as problem-solving with the tradition of design
as enquiry. The applicability of engineering design processes in an
indisputably complex domain, such as integrated ID services, also helps clarify
of the concept of complexity within engineering design. Methodological
contributions are made by developing and applying a research framework for
exploratory design research and by demonstrating the utility of engineering
design tools outside engineering. Furthermore, this study also provides
important insights for the healthcare management literature by suggesting an approach
to distinguishing complicateness from complexity, demonstrating the value of
contributions of currently marginalised stakeholders and showing the
applicability of a mathematical technique for pre-structuring service user
involvement.

The
research is guided by a framework developed specifically for exploratory design
research into the care service domain. An initial exploratory study
investigates design-related issues faced by the local service and to which
degree engineering design is applicable. The predominantly qualitative data is
analysed in diagrammatic form. It emerges that the formal, structural aspects
of the organisation are complicated and suited to an engineering design
approach. However, complex informal aspects, such as customs or personal
relationships, surround the formal structure and are beyond the current scope of
ED design processes but can be addressed by approaches in the design as enquiry
tradition. Four issues are identified which will require amendments to the ED
design process: organisational settings, knowledge management, the lack of a
clear role, and neglected stakeholders.

The
exploratory study is followed up by a detailed study which uses a Delphi
approach to investigate whether the confusion about the role of specialist
services is a general problem in the ID field. It further characterises key
stakeholder groups in ID services in terms of their expertise and level of
agreement or disagreement. The findings outline requirements for new design approaches
that bridge the traditions of design as enquiry and design as problem-solving.

About Me

Despite being a physicist and engineer by background, I have been working on healthcare since 2008. For the first 4 years as a researcher studying the cross roads between engineering design, design thinking, service science and healthcare management. Later, I moved into consulting, where I am working with pharma, medtech and medical services. 2015/2016 I was selected as a secondee to the World Economic Forum, where I spent 11 months trying to figure out how to prevent non-communicable diseases and drive change that allows people to maximize their Healthy Life Years.